January 25, 2011
By Roseanne Spector

(PhysOrg.com) -- Electronic health records did little to improve the quality of health care from 2005 through 2007, even when bolstered by software that gives doctors treatment tips for individual patients.

Thats what two researchers at the Stanford University School of Medicine found by analyzing nationwide physician survey data from nearly 250,000 patient visits over that three-year period.

The study was published online Jan. 24 in the Archives of Internal Medicine.

Theres a lot of enthusiasm and money being invested in electronic health records, said the senior author of the study, Randall Stafford, MD, PhD, associate professor of medicine at the Stanford Prevention Research Center. The federal governments economic stimulus package of 2009 invested $19 billion in health information technology, including incentives for adoption of electronic health record systems. It makes sense, but on the other hand its an unproven proposition. When the federal government decides to invest in health-care technology because it will improve the quality of care, thats not based on evidence. Thats a presumption.

And based on the new study, that presumption is in doubt, at least when it comes to the current use of electronic health records, even those that offer treatment guidance  a feature called clinical decision support.

The new study builds on a 2007 analysis by Stafford and colleagues showing that electronic records alone had not made an impact. In the new study, Stafford and former Stanford undergraduate student Max Romano (now a medical student at Johns Hopkins) analyzed more current data and looked specifically at whether clinical decision support improved the quality of care.

Decision support software provides physicians with specific guidance based on best practice, said Stafford. For example, the computer system might flash up an alert reminding physicians about something they failed to do (for example, checking blood pressure). In other cases, the software might question a particular choice the physician has made about an order for a diagnostic test or a medication. If a physician orders ampicillin for a woman with a urinary tract infection, the computer program will say this isnt the best antibiotic to use and offer better alternatives.

The analysis, based on physician survey data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, revealed that electronic health records were used in 30 percent of U.S. outpatient visits, with clinical decision support software in place for 17 percent of all visits. Other findings were that electronic health records were more likely to be used in the western United States and in group and hospital-affiliated practices than in practices that were smaller or located elsewhere in the country.

Most studies before ours focused on how single EHR systems work in a few premier academic medical centers, and some of those studies have found significant benefits, said Romano. Our study takes a different approach: We looked at all non-federal outpatient settings in the United States, from solo private practices to community health centers, to see whether EHRs were having any noticeable impacts in the real world, and we found no significant differences in care quality.

So why didnt electronic health records translate into better care? These are complicated systems used by individuals who have received little formal training, at least until recently, said Stafford. As a result, physicians might not have made full use of them.

Weve shown that electronic health records and clinical decision support dont by themselves improve quality, said Stafford. If we want improved quality, we have to look at the whole range of issues that affect quality of care and not put all of our hopes on a single technology.

Most people will agree that electronic health records are coming regardless of government action, said Romano. To give a comparison, my supermarket transitioned to electronic records decades ago and my auto mechanic transitioned last year.

If the government is going to spend $19 billion dollars in support of a type of software, he added, that money cant just focus on getting the technology into the marketplace quickly. Perhaps government spending and research should focus more on the issues of quality and equity rather than just broadly endorsing information technology as categorically good.

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6 comments

Despite studies which show no benefit, healthcare pproviders are being pushed to adopt electronic records systems. You would think that costly programs with no benefit would be discarded in the interest of cost control ...

Hmmmm.... To me, the greatest benefit of EHR systems should be that a patient's medical history is instantly available to any doctor anywhere, in useable format, at any time. If I live in Ontario and drive to Quebec, then have a car accident, the Quebec ER staff can instantly access my record to identify any allergies, regular perscriptions being taken and required, special issues etc. If I move to Alberta my medical recdords and those of my family move seamlessly with me.

That of course, is little or no financial benefit to the hospitals or doctors, so in that way, the article may have some accuracy. Obviously for-profit medical orgs in the US will find that having to re-use prior imaging data in electronic format rather than charging the patient for a new complete suite of images looses them money.

Despite studies which show no benefit, healthcare pproviders are being pushed to adopt electronic records systems. You would think that costly programs with no benefit would be discarded in the interest of cost control ...

The reason why they aren't useful is because they're non-standard. Many providers view records from other providers as mere gossip because the records are notes or non-standard format resulting in greater confusion than clarity.

dogbert: You gotta dig deeper into issues than just the superficial profit / loss question. I note that in Canada, some people are complaining about the implementation of the nationwide electronic health record system because none of the radiology technicians which were supposed to become redundant were actually laid off. But they didn't even consider that rad. tech's are always in short supply so obviously would simply be re-assigned from filing / re-analysing films multiple times to actual productive work.

I have experience in a related area. In my former life I was an ERP system programmer analyst. When you implement a big system like these electronic record systems, it usually takes a few years for the users to get comfortable with using the system and start to realize the benefits. People like doctors are famous for doing stuff like continuing to use the old paper method and just having the secretary/nurse type it all into the computer afterwards. Adoption is not an overnight process. This study may be a bit premature. Give it a few years to saturate, then take another look. Look how long it's taken for electronic banking to really take off and become what it is today.

Companies that adopt new ERP software, like the one I worked with or SAP for example, typically see an increased cost and increased problems when they first go live on a new system. Our company typically had boots on the ground on-site at the customer location for over two years. That was my gig, actually.

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